When pain therapies fail

Cassie Winters, 28, who has a degenerative spine condition, holds a spinal cord stimulator, similar to the one she has implanted, at her home in Lindenhurst, Ill., on Friday, December 20, 2013.

Cassie Winters, 28, who has a degenerative spine condition, holds a spinal cord stimulator, similar to the one she has implanted, at her home in Lindenhurst, Ill., on Friday, December 20, 2013. (Andrew A. Nelles, Chicago Tribune)

Julie Deardorff, Tribune Newspapers

Like many people suffering from chronic and debilitating pain, 28-year-old Cassie Winters has tried it all: physical therapy, powerful pain killers, massage, energy healing and meditation. She was even told that finding a new hobby or thinking happy thoughts would get her mind off the pain.

"Nothing worked," she said.

But Winters refused to give up. Though traditional therapies failed, she found a interventional pain specialist, a doctor who can diagnose and treat acute and chronic pain using targeted injections and minimally invasive therapies, often in conjunction with other modalities. Today she says she's finding some relief with a spinal cord stimulator, an implanted device that sends electrical signals to the brain to help mask the pain.

"Pain controls my life," said Winters, whose round-the-clock back and radiating leg pain stems from two childhood spinal fusion surgeries. "I wake up every day wondering how much pain I will be in and whether I will be able to get out of bed. But the stimulator has brought my pain down by about 40 percent."

More than 100 million Americans suffer from chronic pain, a condition that affects more people than diabetes, heart disease and cancer combined, according to the Institute of Medicine. But treating pain is enormously difficult, in part because the source of it often isn't clear, and doctors receive little formal pain management training.

The daily frustration of living with pain, meanwhile, can take a significant toll. Some research suggests that certain conditions, including back pain, migraine and other types of chronic pain without a physical cause and thus little prospect for relief, may also raise suicide risk.

While Winters hasn't reached such a dark place and still feels hopeful, "I have thought if I wasn't alive, I wouldn't be in this pain," she said.

Interventional pain management, a little-known but rapidly growing field, can treat everything from headaches and foot pain to injured vertebrae. Using a variety of techniques, including spinal and joint injections, pain pumps and implanted devices such as the spinal cord stimulator, these treatments are best used when first-line conventional therapies haven't worked, and patients may not want or need surgery, experts say.

Those suffering from a herniated disc, for example, may undergo an epidural steroid injection to reduce inflammation. Once the pain has receded, the patient can return to physical therapy. A patient such as Winters, one who is living with chronic and severe pain and has failed more conservative treatments that another surgery probably wouldn't fix, may try spinal cord stimulation.

"It's for when everything else has failed," said Winters' physician, Dr. Kiran Chekka, a partner at Premier Pain Specialists in Chicago who is board certified in anesthesiology and interventional pain management. "These are the patients whose lives are truly changed. It's not just about making the pain go away; it's about restoring function. The goal is to get people back to work and school and give them their lives back."

Over the last decade, the number of pain medicine practitioners has more than doubled; in 2011, approximately 7,500 physicians were board certified in pain management, up from 3,500 in 2000, according to the American Society of Interventional Pain Physicians.

Because pain treatment is so complex, "pain medicine" is now recognized as a medical subspecialty by the American Board of Medical Specialties.

Yet it's often buyer beware, because pain management is one of the few unregulated fields in medicine, Chekka said.

Any doctor, whether a neurologist, OB-GYN or a primary care physician, can take a weekend course and call himself or herself a pain management specialist. In some areas, a nurse practitioner or physician assistant may perform some procedures, a practice that alarms Dr. David Kloth, a Connecticut-based interventional pain management specialist.

The unqualified or poorly trained practitioners "often have bad outcomes," said Kloth, who has worked to have pain medicine recognized as a distinct specialty. "They can't make a diagnosis or put the needle in the right place. They don't have the skill set to do the procedures properly and don't take the time to make a proper diagnosis. They have a higher rate of complications and often do the wrong procedure for patients, wasting money and exposing the patient to unnecessary risks. It gives us all a bad name."

Winters, who was born with a congenital spine disorder, has seen several pain specialists, including at least one she considers unqualified.

"The last doctor I had was giving me drugs and sending me out the door," she said. "Dr. Chekka really took the time to listen to me. He wanted to try everything possible before giving me the stimulator. And he didn't promise it would heal me. He said, 'Either it will help or it won't. If it doesn't, we'll find something that does.'"

So far, Winters is encouraged that her pain has lessened, though some days are better than others. Usually, pain radiates down her right leg, but when it's cold or the seasons change, both legs are affected. In addition to the spinal cord stimulator, she uses a fentanyl skin patch and the pain medication Percocet to help control breakthrough pain.

One of her goals is to wean herself off the pain medication so she can return to school and finish a degree in graphic design.

"I'd really like to be off everything and be a normal person," Winters said. "It took a long time to come to terms that this is my life. I'm not a very religious person, but I have to pray that days will get better. I have not given up."

Targeted therapies

An interventional pain management specialist uses precision-targeted injections and minimally invasive therapies to help diagnose or treat pain. Here's a brief look at some treatments they offer.

Epidural steroid injections. Steroid medication is injected into the epidural space of the spinal canal to deliver anti-inflammatory medication to the spinal nerves directly adjacent to the disc. This is intended to reduce pain and inflammation in the spine. The medications may block pain impulses, stabilize irritated nerve structures, reduce inflammation and swelling, and reverse the biochemical changes that may occur within the nervous system when pain persists.

Used for: Radiating pain caused by disc herniation, spinal stenosis or degenerative changes in the vertebrae, Dr. David Kloth said.

Spinal cord stimulator. An implantable device delivers low-voltage electrical stimulation to the spinal cord to alter how the brain perceives pain. Using a portable remote, patients are able to adjust the intensity or turn the current on and off. "Some patients find it soothing; others say it's painful," Kloth said.

Used for: Patients with low back pain, especially when associated with leg pain following spinal surgery. Chronic pain that is characterized by severe burning and sensitivity to light touch, swelling and changes to the skin. It may also help pain that persists after a shingles infection, abdominal and pelvic pain and failed-back-surgery syndrome.

Facet block. Steroids are injected into nerves that supply the facet joint, which is on the back of the spine where one vertebra slightly overlaps another. They can also be injected directly into the joint, which can reduce pain and allow the patient to undergo rehab therapy, Kloth said.

Used for: Neck injuries, whiplash. In general, nerve blocks are most effective in those who have pain related to a single or small group of nerves.

Pain pumps: Medication is delivered directly to the spinal fluid and cord, which means patients can receive a much smaller dose than they might require with oral medication. A small pump is surgically placed under the skin of the abdomen. The pump delivers medication through a catheter that is inserted directly into the spinal canal and fluid. .

Used for: Those suffering from spasticity from spinal cord injury or multiple sclerosis or back pain from multiple surgeries, Kloth said.